Christie Blatchford: Tears all around at Ashley Smith hearing as jury hears of orders that paralyzed corrections officers

Tears all around at Ashley Smith hearing as jury hears of orders that paralyzed corrections officers.

Shortly before Ashley Smith asphyxiated in her cell at the Grand Valley Institution for Women in Kitchener, Ont., a senior manager and the head of health care at the prison delivered a devastating one-two punch.

Heather Magee, a grandmotherly correctional manager, was at an “after-ops” briefing one morning when Michelle Brigden, her boss and the acting team leader, flatly told her, “ ‘You don’t go in if she’s [Ashley] breathing.’”

To that, Brenda Tilander-Masse, the head nurse and chief of health care at the prison, offered the helpful tip that, “’You have 90 seconds to go and get her, revive her [Ashley].’

”I was so stunned by that, that it was coming from somebody in health care,” an emotional Ms. Magee told the Ontario coroner’s jury examining Ashley’s Oct. 19, 2007, death.

Jurors have heard, and seen on video, that as Ashley was dying with a homemade noose around her neck that day, paralyzed correctional officers, under massive pressure and explicit orders to stay out of her cell as long as possible, waited outside for too long.

Ms. Magee, who was testifying at the inquest Tuesday, may have been teary but she didn’t entirely lose her wits.

When Ms. Tilander-Masse gave her the 90-second rule, she said, she thought to herself, “I must have missed that bit in my first aid training.”

As Ms. Magee later told coroner’s counsel Marg Creal, “Once somebody quits breathing, I don’t think there’s a guaranteed time for when you can bring someone back.”

Ms. Magee’s evidence added stunning corroboration to what jurors have heard repeatedly at the long-running inquest — senior brass at the prison were desperate to reduce the reportable uses of force involving Ashley and were leaning heavily upon middle managers and guards to avoid entering the teenager’s cell.

Virtually every time COs went into the teen’s cell to cut off a noose, and this happened several times a day, it was deemed a use of force.

But by the fall of 2007, so great was the guards’ collective confusion over what they should do, so often were managers delaying the OK to enter the cell, that on several occasions, the young woman was left alone with a ligature tightly around her neck, her face purple.

No sooner did one of those implicated in the don’t-go-in scheme, special trainer Ken Allan, leave the witness stand than Ms. Magee was sworn in.

It was, if not quite a classic case of going from the ridiculous to the sublime, at least one of moving from the bureaucrat to the humane.

Mr. Allan, a use-of-force reviewer from regional headquarters, was brought to Grand Valley days before Ashley died because of the sheer volume of encounters with the 19-year-old.

Most involved guards cutting off ligatures and then having to justify — ultimately to Mr. Allan — their entry into her cell.

Ashley chronically “tied up” with these nooses, stored them in her body, and fashioned them from anything she could get her hands on.

Multiple witnesses have testified that Mr. Allan told them that COs shouldn’t be going into her cell if she was still breathing.

But Mr. Allan denied that, and in an effort to get a plain answer from him, one of the jurors abruptly burst into tears of frustration.

“I don’t understand!” she wailed, and asked Mr. Allan how such a “high number of reports” didn’t lead him to the bigger picture and instead had him focusing on various technical deficiencies such as how the staff had used the mandatory video camera.

The juror rattled off Mr. Allan’s own words back to him and snapped, “ ‘When to start the recorder’? Who cares at that point?” she said, when “saving someone’s life” was clearly the issue?

To this, a few minutes later, Mr. Allan replied in his oblique way, “I’d like to think I had an opinion and it would be listened to, but my job was to fill in the boxes.”

That was followed by questions, this time icily delivered by another juror, clearly furious.

“Do you think your training was a contributing factor to the correctional officers’ hesitation about going in [Ashley’s cell]?” she asked.

“I don’t think so, no,” Mr. Allan replied.

“So all that stuff about setting up the camera, using too much OC spray, how she [Ashley] was playing a game?”

“That’s a pretty big question,” Mr. Allan said.

The juror continued: Could all those nits he had been picking have “contributed to them not going in the cell”?

Coldly, she pointed out there was no evidence from the other federal institutions where the mentally ill teen had been incarcerated that their staff had become similarly obsessed with the minutia of paperwork.

Didn’t he think, she pressed Mr. Allan, that his focus on technicalities could have added to guards’ “hesitation in cutting off the ligature on Oct. 19”?

“I can’t answer that,” Mr. Allan said slowly.

In his wake, Ms. Magee arrived like a warm, fresh wind.

Like so many of the witnesses from Grand Valley who preceded her, she remains deeply affected by Ashley’s death. She was also fond of the odd, troubled young woman. And like other witnesses, she remembered how when the orders changed, she and another staffer rolled their eyes and muttered, “This is f—ing ridiculous.”

Ms. Magee was so distressed by what Ms. Brigden and Ms. Tilander-Masse told her that day that she filled out a form called an “Officer’s Statement/Observation Report” or OSOR, and recorded their remarks.

“The reason I remember writing it,” she said, “is because she [Ms. Brigden] was my supervisor and it took a lot for me to write it up like that about a supervisor.”

A copy of it was even shown to her by a Justice department lawyer at some point, she said, but the document has apparently been misplaced or lost.

As Ms. Magee put it, “Then it’s gone.”

The inquest was adjourned for about an hour while lawyers scrambled to find the report, but resumed with its whereabouts still up in the air.

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